Best Practices for Imaging Cardiac Device–Related Infections and Endocarditis: A JACC: Cardiovascular Imaging Expert Panel Statement

Vasken Dilsizian*, Ricardo P.J. Budde, Wengen Chen, Sunil V. Mankad, Jonathan R. Lindner, Koen Nieman

*Corresponding author for this work

Research output: Contribution to journalReview articleAcademicpeer-review

44 Citations (Scopus)


The diagnosis of cardiac device infection and, more importantly, accurate localization of the infection site, such as defibrillator pocket, pacemaker lead, along the peripheral driveline or central portion of the left ventricular assist device, prosthetic valve ring abscesses, and perivalvular extensions, remain clinically challenging. Although transthoracic and transesophageal echocardiography are the first-line imaging tests in suspected endocarditis and for assessing hemodynamic complications, recent studies suggest that cardiac computed tomography (CT) or CT angiography and functional imaging with 18F-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) with CT (FDG PET/CT) may have an incremental role in technically limited or inconclusive cases on echocardiography. One of the key benefits of FDG PET/CT is in its detection of inflammatory cells early in the infection process, before morphological damages ensue. However, there are many unanswered questions in the literature. In this document, we provide consensus on best practices among the various imaging studies, which includes the detection of cardiac device infection, differentiation of infection from inflammation, image-guided patient management, and detailed recommendations on patient preparation, image acquisition, processing, interpretation, and standardized reporting.

Original languageEnglish
Pages (from-to)891-911
Number of pages21
JournalJACC: Cardiovascular Imaging
Issue number5
Publication statusPublished - May 2022

Bibliographical note

Funding Information:
Signs of endocarditis on CT images include vegetations, destruction of perivalvular tissue, mycotic aneurysms, abscess formation, and dehiscence (Figure 5) (32,33, 50-52). Vegetations appear as hypoattenuating, often mobile masses of varying size attached to valve leaflets, supporting structures or other intracardiac surfaces and devices. Vegetations, especially smaller ones, are more easily identified on bioprosthetic valves than mechanical valves. Thrombus can have a similar appearance, and the clinical setting often helps in the differentiation. Bioprosthetic valve leaflets may be thickened or eroded, and these morphological features can suggest functional insufficiency. Small, erratically moving vegetations may be missed by CT, particularly if only a single-phase scan is available. Perivalvular involvement is common in PVE. In the case of abscess formation without connection to the blood pool, there is thickening of the aortic root tissue and induration of the surrounding fat. This may be difficult to distinguish from the normal early post-surgical status (53). Destruction of the perivalvular tissue can result in a mycotic pseudoaneurysm with an open connection to the large vessels or chambers of the heart, which fills with contrast-enhanced blood. To differentiate benign suture line aneurysms from endocarditis, prior imaging studies are helpful. When these are not available, calcifications of the cavity wall favor a suture line aneurysm or old mycotic aneurysm. In the case of prosthetic valve dehiscence, a space may be visible between the prosthesis and the surrounding tissues, and discordant mobility (rocking) may be observed on multiphasic reconstructions if the dehiscence covers a large part of the valve circumference. The presence of suture pledgets can mimic a paravalvular leakage; however, their orientation (multiple and arranged in a circular manner around the valve) and hyperdense appearance on noncontrast-enhanced acquisitions are key features (Figure 4).

Publisher Copyright:
© 2022 American College of Cardiology Foundation


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